


Initial Assessment

by propinquitous



Category: Supernatural
Genre: Eating Disorders, Gen, Hallucifer, Hallucinations, Implied/Referenced Alcohol Abuse/Alcoholism, Implied/Referenced Rape/Non-con, Implied/Referenced Self-Harm, Implied/Referenced Torture, Medical Jargon, Psychological Trauma, Sam Winchester and Mental Health Issues
Language: English
Status: Completed
Published: 2015-02-19
Updated: 2015-02-19
Packaged: 2018-03-13 20:10:25
Rating: Teen And Up Audiences
Warnings: Creator Chose Not To Use Archive Warnings
Chapters: 1
Words: 921
Publisher: archiveofourown.org
Story URL: https://archiveofourown.org/works/3394823
Author URL: https://archiveofourown.org/users/propinquitous/pseuds/propinquitous
Summary: <blockquote class="userstuff">
              <p>What Sam's assessment might have looked like when he was hospitalized in The Born-Again Identity.</p>
            </blockquote>





	Initial Assessment

**Author's Note:**

> This was an exercise in writing assessments - I'm not qualified to make diagnoses, so they're purposefully limited. There are mentions of medication, self-harm, physical/sexual/emotional abuse, eating disorders, and electroconvulsive therapy (electric shock therapy). This is entirely hypothetical, and I did my best to avoid the dehumanizing language I've seen in a lot of assessments. **Still, it might be triggering if you have a history of psychiatric treatment or hospitalization.**

Samuel Smith (Sam) was brought to the emergency room following a hit and run accident. Upon initial evaluation in the ER, further evaluation by the on-call social worker, and treatment of his physical injuries, he was transferred to Twin Lakes. He is currently under care in a locked psychiatric unit due to the possible injury to himself or others. He reports that he has not slept in close to six days, and that attempts to self-medicate with alcohol have not helped. Since his transfer to Twin Lakes nine hours ago, he has been given 1.5mg of clonazepam and 250mg of trazadone to no effect. He is also receiving 200mg of ibuprofen every four hours for pain related to the accident, as he has several bruises and lacerations. Further observation is necessary and the treatment team recommends that he remain on the locked unit until the insomnia resolves.

  
In addition to his severe insomnia, Sam reports auditory and visual hallucinations. He believes that Lucifer, or the Devil, is speaking to him and keeping him awake. In addition, he believes that Lucifer is following him because he prevented the apocalypse, which Lucifer wanted to happen. He has also made references to his time “in the cage” with Lucifer, and made inappropriate jokes about the physical and sexual abuse that occurred there. Whether or not such abuse occurred is unclear, but it appears likely that Sam has a history of physical, emotional, and/or sexual trauma. Given his reluctance to speak about the hallucinations, it will likely take considerable one-on-one time and relationship building with a therapist before he is willing to talk about his past.

  
Fortunately, Sam does not seem to have violent impulses toward himself or others. Despite his unstable state he appears relatively calm, cooperative with staff, and kind to other residents. With the exception of some gallows’ humor, his behavior is generally appropriate for the situation and he exhibits a congenial demeanor. However, given the religious and persecutory nature of his delusions, the possibility of violent behavior cannot be ruled out. It is also unclear if the delusions are being caused by the insomnia or if the insomnia is the result of the delusions; as such, it is impossible to make even a preliminary diagnosis until he is able to sleep. Antipsychotics and other medical treatment remain off the table until further evaluation can be made.

  
Of additional concern is the high concentration of scars on Sam’s arms and legs. Though he has not disclosed any past or current self-injury, the presence of such scars indicates that there may be some history of it. He also has a large scar on his left hand that he squeezes when he appears distressed, which implied to his intake psychiatrist that he uses pain as a coping mechanism. Due to his self-medication prior to hospitalization, it is also possible that he has abused alcohol or other drugs. While we do not know how long he might have been using, he is under careful observation for symptoms of withdrawal.

  
Since entering the locked unit, Sam has also expressed a reluctance to eat. He reports seeing maggots in his food, which reappeared with each meal, and he has consumed under 500 calories since hospitalization. Additionally, despite his extreme exhaustion and lack of caloric intake, he has repeatedly asked to go outside so that he can jog and has been observed doing pushups in his room. Given this extreme exercise and limited food intake, it appears likely that Sam experiences disordered eating. However, as with his other symptoms, these behaviors cannot be properly evaluated until he has slept.

  
With regard to family, Sam’s brother Dean has visited the hospital twice since his admittance. Sam asks to see him regularly, though such a visit is not possible until he has stabilized. Dean acknowledges that Sam has not been well recently, though he has been reluctant to disclose any information apart from the insomnia. He did report that he and his brother live together on their own, which they have done since the death of both of their parents. He also stated that they have no living relatives, and that Sam does not have any friends or a partner, which supports Sam’s initial intake data. While Dean does seem to care deeply for his brother, he appears uncomfortable with hospital staff and the extent to which he will participate in Sam’s treatment is unclear. Still, it is advisable that the treatment team keep Dean involved and informed where appropriate and in HIPPA compliance, especially given how often Sam has expressed a desire to see him.

  
Overall, very little evaluation can be made until Sam is able to sleep. We believe that he is unable to give informed consent in his condition, and his brother has rejected ECT for the time being. If his insomnia does not resolve within the next two to three days, he will need to be transferred to a specialized hospital for treatment of possible Fatal Familial Insomnia. Given the rarity of this disease, it is unlikely that such a diagnosis is viable; however, it is impossible for his treatment team to exclude or make such a diagnosis given its lack of expertise in the area. In the meantime, the team will meet regularly to determine other options, particularly a possible increase or change in medication to induce sleep. In the coming weeks, we recommend that Sam meet daily with a psychiatrist and nutritionist, as well as a peer support specialist as he stabilizes.


End file.
